TREATMENT SELECTION: HOW TO CHOOSE THE FACILITY AND LEVEL

OF CARE

CAPTASA 2015LEXINGTON, KY

THE PRACTICE GAP

• Many people are not placed in optimal treatment environments• Often, decisions driven more by administrative or patient preference,

rather than clinical needs• Assessment and treatment occurring within the same organization-

potential for conflicts of interest• Newly diagnosed cases may need very different treatment than those

with relapse- even if the “facts” are similar

“WARM BEER AND COLD WOMEN, I JUST DON'T FIT IN

EVERY JOINT I STUMBLED INTO TONIGHT-

THAT'S JUST HOW IT'S BEEN”

WARM BEER AND COLD WOMEN-TOM WAITS

BEFORE WE GO ON… SOMETHING NICE

ASAM SIX (6)DIMENSIONS: THE CLIENT’S RISK STATUS IN EACH OF THE SIX DIMENSIONS COLLECTIVELY INFORM THE PATIENT PLACEMENT DECISION.

1. Acute Intoxication and/or Withdrawal Potential.2. Biomedical Conditions and Complications.3. Emotional, Behavioral, or Cognitive Problems and Complications.4. Readiness to Change.5. Relapse, Continued Use, or Continued Problem Potential6. Recovery Environment. *** Safety Sensitive Professions have own criteria***

IT’S A CLINICAL DECISION NOT A CHECKLIST

• Criteria are NOT substitutes for GOOD Clinical Judgment.• Selection Tools and Criteria support, guide and

enhance GOOD Clinical Judgment!

ASAM LEVELS OF SERVICE:

• Level 0.5 Early Intervention• Level I Outpatient Treatment• Level II Intensive Outpatient / Partial Hospitalization• Level III Residential/Inpatient Treatment• Level IV Medically Managed Intensive• Hospital/Inpatient Treatment

ACUTE INTOXICATION AND/OR WITHDRAWAL POTENTIAL

• History of recent use• Alcohol always first billing• Benzos or Z-drugs• Combinations are worse• Route of use• Past Detox and/or withdrawal experiences• Concomitant medical conditions• Age

BIOMEDICAL CONDITIONS AND COMPLICATIONS• Overlaps with above• Includes unrelated but complicating factors like

surgeries, recent injuries• Sensory deficits and other challenges• Special conditions- Pregnant, dialysis…• Chronic Pain (careful! Self reports are very poorly

correlated with outcomes)• Mobility issues

EMOTIONAL, BEHAVIORAL, OR COGNITIVE PROBLEMS• Any other Psychiatric Dx• Mood or thought D/O• Suicidality• Aggressive behaviors• Uncooperative attitudes and behaviors• Criminal behaviors• Delirium• Cognitive decline

MY LIST OF “OTHER DX’S”

•CAIDs•DITTs•DAIGHOMBs

READINESS TO CHANGE

• What is the motivator?• Stages of Change• Acceptance-Denial spectrum• Are they willing to be there and not disrupt others?• Where is the leverage?

PROCHASKA AND DICLEMENTE

RELAPSE, CONTINUED USE, OR CONTINUED PROBLEM

• Danger and damage of continued use or relapse• Consequences and their Legal situation• Level of insight• Relapse triggers• Their history of treatment and relapses• Use while in treatment

RECOVERY ENVIRONMENT

• Huge criteria• Makes for more quick relapses than anything else• Where they live, who with and work environment…• Access to drug of choice• Dangers, especially domestic violence• After acute withdrawal is addressed, this is most pressing

safety issue

SPECIAL SITUATIONS• Pregnant or with children• Gender• Adolescents• Corrections• Safety Sensitive Professionals

ADDICTION'S SHRINKING GENDER GAP

• All over the world, women have always had lower rates of addiction than men. But when women gain more rights as nations grow richer, they begin to catch up; in one drug type, they're already ahead.• There is one notable exception in the gender gap,

one substance that women use and abuse in greater numbers than men: tranquilizers.

• Kelly Bourdet 03/07/13 The Fix

MY EXPERIENCE AND OBSERVATIONS

• ASAM Criteria are most useful if you don’t do this work full time

• ASAM Criteria are primarily about who will get paid and how long treatment is approved

• Insurance Companies use it to avoid or deny treatment

• Correlates OK for section of patients in middle of the Bell curve, but very poor at margins

• Takes a lowest possible initial level approach and moves up if lower level fails

• That can use up resources and commitment on front end- my biggest concern with it

• I found it useful as an organizational tool, but rarely made decisions based on it

WHAT ELSE I HAVE NOTICED

• Treatment for Addictive disorders is less standardized than any other area of medicine

• Same clinical situations can be placed and treated almost anywhere in the spectrum

• Treatment of Addictions is like real estate- Location, Location, Location

• The Treatment community (some) took advantage of the surge in funding back when- now we are facing the consequences

• The single most important driver of selection is what do you have at hand

• Second is how much leverage do you have with the person who needs treatment

BRAVE NEW WORLD?

ABSTINENCE VS HARM REDUCTION

• Well I don’t have much problem with this myself• Society just wants “them fixed” and quickly• And money drives both sides- Providers and Payers• The patients usually opts for what is quick and easy• Harm reduction is the most common approach now (Standard

of Care by most estimates)• What passes for treatment is often a business model rather

than a clinical model• I think CAPTASA serves as a place to hear the alternative

SO WHAT ARE WE TO DO?

• Know your Local resources• Know you own strengths and limits• Decide what you believe about Addiction and treatment• Keep up with what you see work and what doesn’t• Remember this is a Chronic, Progressive and Fatal Illness- so relapse

happens and we don’t always get a good outcome• Take good care of yourself- I think Alanon helps Helpers help• If you are in Recovery yourself you need more meetings and Recovery

work, not less!

THANK YOU